Referring Authority Referring Team Address Name of Social Worker/Health Worker Contact Telephone Number Email Address Name of Manager Contact Number Email Address
Service User Name Service User Address Gender Date of Birth Legal Status Ethic Origin Religious Needs NI Number Next of Kin Contact Address Relationship to Service User Contact Telephone Number GP Name GP Address GP Contact Number Brief Background Information Please include any diagnosis Communication. Are there any issues around communication that we need to be aware of?
Details of any Physical and/or Mental health Issues Medication Details. Please include frequency and route as well as assistance required Personal Hygiene. include details of assistance required with washing toileting and continence and Dressing What are the contact arrangements with family/significant others Other Health Agencies involved and Contact Details Daily Living Skills. Please identify the level of assistance required with cooking, cleaning, laundry, shopping and budgeting Has the Service User got any behavioural issues, ie violent, aggressive or self-harm and/or any other behavioural issues that you feel that we need to be aware of? Has the Service User any criminal convictions or current charges against them? (if yes, please give details) Are there any issues of alcohol and/or substance misuse? (if yes, please give details) Are there any issues that we should be aware of in relation to allegations against staff? (if yes, please give details) What is the Service Users view about a placement with Hengoed Park Ltd? Has the Service User had funding agreed in principle? When would want the placement to start? Will the Service User require us to supply accommodation? Are there any other Agencies apart from Health Agencies involved with the Service User? (if yes, please give details) Is there any other information that we need to be aware of? Please supply any reports that you feel may be appropriate for the assessment for this referral.
Referral Contact Deputy Manager Telephone: 01691 650454
